PATIENT INFORMATION. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
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1 Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS: (_) Single (_) Married (_) Divorced (_) Widowed (_) Separated MAILING ADDRESS: STREET: CITY: STATE: ZIP HOME PHONE: ( ) WORK: ( ) CELL: ( ) RELATION TO INSURED: (_) SELF (_) SPOUSE (_) CHILD (_) STEP CHILD (_) OTHER PRIMARY CARE PHYSICIAN: PHONE #: ( ) PHARMACY: PHONE #: ( ) HOW DID YOU HEAR ABOUT ADVANCED DERMATOLOGY? PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient NAME (Last, First M.I.): DATE OF BIRTH: / / SSN#: SEX: (_) Male (_) Female MAILING ADDRESS: STREET: CITY: STATE: ZIP HOME PHONE: ( ) WORK: ( ) CELL: ( ) Please list everyone that you authorize us to share information regarding your care: (for instance children, parents, or partners who can receive test results, etc.) **LEAVE BLANK IF WE ARE ONLY TO SHARE INFORMATION WITH THE PATIENT** I agree that the names I listed above can receive any information on my behalf regarding my medical records, results, etc. (initial here) WOULD YOU LIKE TO LEARN MORE ABOUT OUR COSMETICS? (_) YES (_) NO If Yes, Please describe what you would like information on: TO BE FILLED OUT BY OFFICE: Primary: INS CARRIER: ID# MEDICAL GROUP: COPAY: Secondary: INS CARRIER: ID# MEDICAL GROUP: COPAY:
2 MEDICAL QUESTIONAIRE Date: NAME (Last, First M.I.): DATE OF BIRTH: / / DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: YES NO Skin Cancer/Melanoma Blood Transfusions Acne/ Accutane Dates: Cold sores Keloids/ Bad scars Surgery / Hospitalizations: Eczema/ Skin Rashes DATE: Opreation Type: Difficulty with wound healing Difficulty with skin infections Psoriasis Asthma/ Hay Fever/ Hives/ Sinus Issues Rheumatic Fever Heart Disease High Blood Pressure YES NO Have Any Blood Relatives Had Any Of The Following: Heart Murmur/ Mitral Valve Prolapse Skin Cancer Artificial Joint, Heart valve, Prosthesis Melanoma Pacemaker or Defibrillator Asthma/ Hay Fever Kidney Disease Eczema/ Skin Rashes Glaucoma Diabetes Diabetes Psoriasis Tuberculosis Other Skin Disease: Blood-Bourne Infections Autoimmune Disease (Lupus, Rheumatoid Arthritis) Hepatitis B OR C (Please Circle) Are you Allergic To any Medications? Do you have sensitivity to Lidocaine or Epinephrine? ( ) YES or ( ) NO Are you Currently Taking Medications or Vitamin/Mineral Supplements? (PLEASE LIST) IF NONE, CHECK HERE YES NO OTHER QUESTIONS YES NO FOR FEMALE CLIENTS ONLY Are you in good health? Are You Pregnant? Do you sunbathe? Are you Nursing? Do you use Tanning Booths? Do you take Birth-Control? Do you need Antibiotics before Dental Surgery? If YES, name: Do you Bleed easily? Date of Last Menstrual Period: Are you inder the care of a Physician / / If YES, Please List Conditions:
3 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 NOTICE OF PRIVACY PRACTICIES Notification is hereby given that Advanced Dermatology shall not reveal or disseminate any personal information about you or your dependents without your permission. Your information shall never be sold, or listed for purpose of advertising, fundraising or solicitation. I, (Patient/ Patient s Representative) do understand that within the context of doing business and providing general healthcare services, my personal information will be necessary and vital and may be used in the following ways: Patient Registration. Obtain medical records from previous physicians and/or ancillary medical providers. Consultation with other medical providers as may be necessary for medical care and/or treatment options. Insurance verification and billing matters. Including interaction with billing company, insurance companies and other necessary and proper related matters. Pursuit of unpaid medical bills and collection of unpaid medical bills. Office staff, medical assistants, physicians. Emergency medical services (Fire, Paramedic, Police, and Hospital Staff) in the event such a need may arise. Personal religious designate Completion of disability forms Computer and electronically stored information (including business vendors and service personnel) In the event you desire a copy of this Notice of Privacy Practice you may contact Advanced Dermatology and skin cancer specialists at the following: Advanced Dermatology and Skin Cancer Specialists Corporate Office Tel: Fax: S. Temecula Pkwy Suite #203 Temecula CA I have read the Notice of Privacy Practices and hereby authorize the release of this necessary information: Patient/Patient Representative (Signature) Date: Patient/ Patient Representative (Print Name)
4 MEDICAL RECORDS RELEASE FORM Authorization for use or Disclosure of Protected health Information As required by the health information Portability and Accountability Act of 1996(HIPPA) and California Law, Advanced Dermatology and Skin Cancer Specialists, may not use or disclose your individual identifiable health information except as provided in our notice of privacy practices without your authorization. Your completion of this forms means that you are giving your permission for the use disclosures described below. Please be aware that once your information leaves Advanced Dermatology and Skin Cancer Specialists, we will no longer be able to protect that information, and the recipients of your information may not be legally required to protect your information. I hereby, release Advanced Dermatology and Skin Cancer Specialists from any/all legal liability that may arise from the release of this information to the party listed below. Further, I authorize Advanced Dermatology and Skin Cancer Specialists to obtain or disclose health information concerning: Patient Name: Date of Birth: / / Health Information to be released or Disclosed History/ Physical Exams Telephone Messages Lab Results Entire Medical Records Consultation Report X-Ray Results Progress Notes Biopsy/ Surgical Pathology Site I understand this information may include information relating to AIDS (acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, STD s (Sexually Transmitted Disease) and treatment for alcohol and/or drug abuse. Please make sure that all physician or contact information is filled out completely. Request with missing information will not be honored. Initial Information to be released to: From: I understand this authorization may be revoked in writing at any time, according to Advanced Dermatology and Skin Cancer Specialist Notice of Privacy Practices. Unless otherwise revoked, this authorization will expire One year from date of this authorization. Printed Name: Date: / / Signature: Witness: If signed by other than patient, indicate relationship:
5 ACKNOWLEGMENT OF INSURANCE Patient s Name: Date of Birth: / / I am enrolled in: (Name of insurance company) With: (Medical Group) I understand that if I am no longer eligible with the above named insurance or my insurance has changed or terminated, I or the person financially responsible for me, will assume full responsibility for all charges incurred by myself. If HMO: I am aware that my HMO requires me to be assigned to this office/doctor. If I am not assigned to this office/doctor, I or the person financially responsible for me will assume full responsibility for all charged incurred by myself. I agree that if the above is not true, I or the person financially responsible for me will pay in full all such charges. Patient/ Responsible Party Signature: Date: / /
Advanced Dermatology and Skin Cancer Specialists
PATIENT INFORMATION (Please complete all sections) Date: Office Location: NAME(Last,First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GARDIAN(S): SSN#: SEX: (_)Male (_)Female MARITAL STATUS: (_)Single
Patient Information *Please Complete All Sections*
Front Desk Check-In Initials Patient Information *Please Complete All Sections* Account # (Office Use Only) Name (First, MI, Last) Date of Birth / / Age: Sex: M F Mailing Address Apt # City State Zip Home
Natural Image Skin Center Registration Form
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List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)
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Street Address Apt. No. City State Zip. Race: Ethnicity: Hispanic Not Hispanic or Latino. Marital Status: Single Married Widowed Divorced
Patient Information MRN# Patient Name: Address: Street Address Apt. No. City State Zip Age: Birthdate: *Social Security: Phone:Home# Work # Cell # Gender: Male Female Primary Language: Race: Ethnicity:
NOTICE ABOUT REFRACTION
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Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
I do / do not (circle one) authorize Vitalogy Skincare and its designated representatives to release medical information to (print name) Relationship
RECEIPT OF NOTICE OF PRIVACY PRACTICES I, (print patient name), have read a copy of Vitalogy Skincare s Notice of Privacy Practices. (This document is available at the front desk or at Vitalogyskincare.com.)
PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code
PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION:
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
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Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
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CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY Name Age Date of Birth Email _ Reason for today s visit Who referred you to this office _ Who is your primary care physician? Are you allergic
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1600 N Coalter St, Ste 19 Staunton, VA 24401 Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON
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PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
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PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home
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Byron J. Van Dyke, M.D. Medical, Surgical, & Cosmetic Dermatology 1158 N. Court Street, Redding, CA Tel (530) Fax (530)
PATIENT: Date of Birth Gender: Male Female Ethnicity: Hispanic Non-Hispanic Single Married Divorced Widowed Race: Caucasian/European-American African/African-American Asian/Asian-American Native American
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Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
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Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
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Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext. Date of Birth: Sex: M F Social Security Number:
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❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
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Brighter Smiles Family Dentistry Welcome To Our Office! Our team believes that our patients are the most important people in the world. We appreciate that you have chosen our team as your dental family.
HIPAA Patient Consent Form
HIPAA Patient Consent Form Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
PATIENT REGISTRATION FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
New Patient Information
New Patient Information Name: : What name would you like to be called?: of Birth: Home Phone: Social Security No: Cell Phone: E-mail: Address: City: State: Zip: Employer: Work Address: City: State: Zip:
Georgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
Conway Regional After Hours Clinic
Conway Regional After Hours Clinic Patient Information Patient Name: Date of Birth Sex (M) (F) SS# Marital Status M S W D Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Mailing Address: Street City
Name Last First Middle Address. City State Zip. Home Phone ( ) Date of Birth Age Marital Status. Work Phone ( ) Address. Employer Occupation
PATIENT INFORMATION Name Last First Middle Address City State Zip Home Phone ( ) Date of Birth Age Marital Status Cell Phone ( ) Social Security # Male Female Work Phone ( ) E-mail Address Employer Occupation
Dr. Víctor Vergara DMD P.A Livingston Rd, Bldg # 100, Ste. #106, Naples, FL Fax PATIENT HEALTH RECORD
! Dr. Víctor Vergara DMD P.A. 239-263-0912 13180 Livingston Rd, Bldg # 100, Ste. #106, Naples, FL 34109 Fax 239-263-0925 PATIENT HEALTH RECORD PATIENT INFORMATION Date (Month/Day/Year) / / DATE OF BIRTH
Get Serious About Your Skin
PATIENT INFORMATION: Today s Date First Name Last Name Middle Address Apt. City State Zip E-Mail Address Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth Age Social Security Number Sex: o M o
FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male
McDonnell Dermatology, LLC Olympia Ave Suite 204 Punta Gorda, FL Phone Fax Patient Care Policy Letter
McDonnell Dermatology, LLC 25097 Olympia Ave Suite 204 Punta Gorda, FL 33950 941-205-3376-Phone 941-205-3379 Fax Patient Care Policy Letter Welcome to McDonnell Dermatology, LLC. Our mission is to provide
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medicare Patient Registration
Medicare Patient Registration Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
Lowrance Dental REGISTRATION FORM (Please Print)
Today s Date: Patient s last name: First: Middle: Lowrance Dental REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Is this your legal name?
Madison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
PATIENT REGISTRATION
Date: How did you hear about us? Name of previous dentist: PATIENT REGISTRATION PATIENT INFORMATION First Name: Last Name: Middle Initial Preferred Name: Birth Date: / / Age: Male Female Soc Sec: - - Address:
PATIENT REGISTRATION
TIME 2:51 PM DATE 6/26/2013 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred